Structural determinants in MSM HIV preventionenvironmental and structural factors predict internalised homonegativity in men who have sex with men (MSM) : findings from the European MSM internet survey (EMIS) in 38 countries

• Background: Varying patterns of policy and cultural disadvantage among sexual minorities have recently been pointed to as implicated in their poorer health outcomes, relative to the heterosexual majority. We examined the precursors of internalised homonegativity (IH) within a macro-meso-micro framework, using various data sources, to help disentangle the complex influences perpetuating homonegative internalisations among European MSM. Methods: EMIS is a collaborative study across 38 countries which during summer 2010 recruited over 180,000 MSM via Internet sites. The survey included a culturally stable form of the IH scale and various beliefs and behavioural variables. Additionally, to broaden the view of macro and meso environment at the level of individual men with respect to IH, we combined country-level data from the World Economic Forum, LGB status list, and European Values Survey. Results: The analyses included 38 countries and 144,177 MSM with a valid IH score, which varied across Europe, with the highest scores found in Southeast Europe. In multivariate analyses, at the societal structure of rule-systems, higher IH was predicted by the absence of legal rights (b.37 to .42). At the meso-level, IH was predicted by cultural values regarding homosexuality (b.16). At the individual level, greater homonegative internalisation was found among those men who perceived they could not access PEP and HIV and STI testing in their country (b.21 to .22). Higher IH, in turn, was associated with not testing for HIV and STIs (b.70 to .57). Conclusion: As possibly the first multi-level study, EMIS shows that a homonegative structural and social climate appears to have pervasive effects on MSM’s evaluation of the self, and greater IH in turn affected men’s levels of HIV precautionary behaviours. In addition to the human rights aspect, the EMIS results suggest that improved affirmative policy environments will have positive health impacts on MSM populations.

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